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Angelina Jolie's double mastectomy shines a light on cancer decision-making

Angelina Jolie’s double mastectomy shines a light on cancer decision-making

Angelina Jolie’s announcement this week that she had both breasts surgically removed to reduce her risk of breast cancer has raised lots of questions about how to best prevent the disease in the women at highest risk of it.

As she revealed Tuesday in a New York Times Op-Ed, the actress and activist made the difficult decision to undergo a preventive double mastectomy after genetic testing revealed she carries the BRCA1 gene mutation, which increases a woman’s risk of both breast cancer and ovarian cancer, of which her mother died at age 56.

The procedure took her lifetime risk of developing breast cancer from an estimated 87 percent to less than 5 percent, Jolie wrote.

The news caps off what’s turned out to be a full month of revelations about preventing breast cancer in the women at highest risk of it. In mid-April, the U.S. Preventive Services Task Force released draft recommendations advising that doctors offer the preventive drugs tamoxifen or raloxifene to their patients at elevated risk of breast cancer and low risk of adverse events from the drugs, which can cause dangerous blood clots.

And on April 30, The Lancet published the results of a large meta-analysis which found that not only can tamoxifen and raloxifene reduce (Evista) a woman’s risk of developing breast cancer by nearly 40 percent, but the benefits last for at least 5 years after the drugs are stopped—a revelation that could tilt the risk-benefit ratio in favor of more women taking the drugs, which currently aren’t widely used because of the clotting concern.

Jolie’s announcement in particular is likely to have a lot of women with a strong family history of cancer pondering whether they, too, should have their genes tested—and moreover, whether it’s plain irresponsible not to. It’s a difficult question. While women who carry BRCA mutations face a heightened risk of breast cancer, the genes account for only a small fraction of breast-cancer cases overall. The presence of the mutation doesn’t guarantee a woman will develop breast cancer, nor does its absence guarantee that she won’t. And the test is expensive, upwards of $3,000, though insurance plans will now be required to cover it for high-risk women under the Affordable Care Act.

For perspective, I reached out to my colleague John Santa, M.D., director of the Consumer Reports Health Ratings Center. He emphasized that BRCA testing is appropriate only in women who have a strong family history of breast or ovarian cancer—and that it’s critical that the results be used in concert with that history to decide whether to pursue preventive treatment.

“Women who have a family history of breast or ovarian cancer, especially in multiple family members or at a young age, should sit down with a physician knowledgeable about breast cancer and the genes involved. If needed, a genetic counselor should be consulted. If a woman then decides to have the test, the results should be reviewed with those same experts to determine what, if anything, to do next. There are many possible approaches based on the test and patient’s family history. Women without a positive family history are more likely to be confused and possibly misled by BRCA testing.”

For those women, the good news is that breast cancer is among the few cancers for which there’s strong evidence that screening, in the form of mammography, can save lives—though that’s mostly true for women 50 and and older, and most need the test only every two years, not every year. For more, see our review of 11 cancer screening tests, including eight you should skip.

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